1 Report
Inspection Report — Mar 18, 2025
Routine
Date: Mar 18, 2025
Visit Reason
Biennial state compliance review of the assisted living residence by the Massachusetts Executive Office of Aging & Independence (AGE) on March 18, 2025.
Findings
The state cited 5 findings, including 3 repeat findings, below the state median of 6. The action taken was Plan of correction required.
Citations (5)
Emergency call response: During December 2023, June 2024, and January 2025, there were 162 emergency call response times over the ten-minute limit. Documentation of management testing the system for 2023 was missing, and required six-month assessments by a physical/occupational therapist for 19 Residents using bed rails or U-bars were missing (repeat finding).
Resident screening and assessment: Missing Bedrail assessments.
Quality assurance program: Documentation of a target date for follow up action was missing for all four quarters of 2023. Two Residents’ medication storage units contained expired medications and medications not on the current medication list (repeat finding).
Incident reporting: The Residence filed 34 incident reports more than 24 hours after the occurrence of the incident or accident (repeat finding).
Staff training: Documentation of General Orientation for seven staff records was incomplete. Seven Resident records lacked documentation supporting consistent Introductory Visits prior to or within 48 hours of move-in or condition change.
Report Facts
Findings: 5
Repeat findings: 3
State median findings: 6
Emergency call responses over ten-minute limit: 162
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